WHAT IS ARTHRITIS? PATIENT EDUCATION: HIP & KNEE ARTHRITIS

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1 KNOWS River Valley Ortho PATIENT EDUCATION: WHAT IS ARTHRITIS? Arthritis literally means joint inflammation. Several forms exist, the most common being osteoarthritis, or wear-and-tear arthritis. Other types include those in which the body s immune system gets confused and attacks parts of the joint, such as in rheumatoid arthritis or psoriatic arthritis. Gouty arthritis occurs when excessive uric acid in the blood stream deposits in the joint causing inflammation. To understand arthritis better, it s important to know some basics about the anatomy of a joint. A typical joint is where two or more bones meet. In the knee, it is where the femur (thigh bone), tibia (shin bone), and patella (knee cap) come together. In the hip, it is where the femur (thigh bone) and the acetabulum of the pelvis (socket) meet. In order for these bones to slide against each other and allow pain-free motion with minimal friction, the bone ends are each coated with hyaline (articular) cartilage. This type of cartilage is extremely slippery and usually works for years, but unfortunately, can wear out. The body is not good at replacing cartilage, and instead scar begins to form instead, or it simply wears away, not unlike the tread on a tire. And as a general rule, once it s gone, it s gone. Normal Knee Normal Hip Image credit: This process itself is not necessarily painful. In fact, bones and cartilage do not have a great deal of pain-sensing nerve endings themselves. Instead, it is the inflammation that this process may cause that irritates the surrounding joint lining and causes pain. As the arthritis progresses, more cartilage is lost, the joint loses range of motion, and bone-on-bone contact eventually occurs. Bone spurs (osteophytes) form around the margins of the joint, and ligaments and other surrounding structures of the joint may be compromised over time. Page 1 of 7

2 WHAT CAN BE DONE FOR ARTHRITIS? PATIENT EDUCATION: Treatment revolves around control of symptoms & pain, reducing stress on the joint, avoiding further injury, and eventually, potential joint replacement or other surgical options may be considered. Even though treatment options may seem benign, it s important to remember that everything can have some associated downside that can adversely affect your overall health. HOW ARE PAIN SYMPTOMS CONTROLLED? Most pain symptoms are related to the inflammation associated with arthritis. By controlling inflammation, pain can be reduced. This can be done by taking nonsteroidal anti-inflammatory medications (NSAIDs), such as over the counter ibuprofen, Advil, Aleve, or other similar prescriptions. These have been a mainstay of arthritis treatments for many years. However, more recently these have been noted by the FDA to increase risk of heart attack, stroke, kidney disease, and GI (stomach and intestines) ulcer in at risk patients. This risk is directly related to the length of time, frequency, and dose taken. These medications can also increase bleeding risk, and should be used only after clearance from a primary care physician in patients who are already taking prescription blood thinners. They should be avoided in patients with history of heart attack, stroke, GI ulcer, or kidney disease or impairment, unless otherwise directed. Arthritic Knee Image credit: Arthritic Hip Page 2 of 7

3 Steroids are another type of anti-inflammatory that can be considered. Occasionally, an oral steroid may be prescribed for a short time by your primary care doctor. More frequently, an injectable steroid ( cortisone ) may be recommended by your orthopaedic doctor, to be placed inside the affected joint itself. This can often provide more effective and extended periods of relief without the major side effects associated with taking an oral steroid, or NSAIDs alone. Limits to this type of treatment include a maximum of 3 injections per joint, per year, which have to be space at least six weeks apart. Temporarily elevated blood glucose (blood sugar) is expected in patients with diabetes for 2 to 3 days following any injection, and should be controlled accordingly. Nutritional supplements (vitamins) are another option. These are least researched, but seem to have the lowest risk of side effects. The most researched of these includes glucosamine-chondroitin. This is made from crushing and purifying the shells of shellfish, so those with a shellfish allergy should avoid glucosaminechondroitin. Admittedly, the science behind this supplement doesn t make a whole lot of sense to us, but a large randomized controlled study in a noted peer-reviewed journal identified that about two-thirds (66%) of patients taking this for two weeks or more have significant reductions in knee arthritis pain. Our experience in this office is similar. Though it may not eliminate pain, it may improve function and decrease the use of NSAIDs. It is available in many different name-brand and generic formulations, and we recommend a reputable cheap generic (e.g. Walgreen s, Target, Meijer, etc.). It should be tried for at least 30 days, and if no significant change in symptoms occurs, can be abandoned. Other nutritional supplements in question include fish oil, and it seems there s an ever-increasing array of vitamins and nutritional supplements offered online or in stores for arthritis. One thought of caution: these supplements are rarely scientifically evaluated, and any purported studies are typically funded by the companies who manufacture them (excluding glucosamine-chondroitin). Just because there are no reported side effects, does not mean that they don t exist. Additionally, they are not regulated by the FDA, and are not covered under most insurance drug plans. Finally, pain medications, specifically meant for reducing pain itself can be used alone or in conjunction with the other medications listed. Most commonly, acetominophen (Tylenol) is a typically safe over-the-counter medication that most people can use. It should be avoided by people with liver disease (hepatitis or the like). It is also included as a component in many other narcotic pain medications (e.g. Vicodin, Norco, Percocet), and the 24-hour limits for this medication (typically 3,000 to 4,000 mg) should be carefully followed. Other non-narcotic pain medications include tramadol (Ultram), which is available by prescription. This should only be used if other alternatives are not working. Page 3 of 7

4 Narcotic pain medications should be used only as an absolute last alternative, as they are addictive and can cause dependence, as well as decreased pain tolerance. Additionally, patients who are on narcotic pain medications prior to any surgery have much greater difficulty with pain control post-operatively. Prescriptions for narcotic pain medications prior to, or over 12 weeks after a surgery should come from your primary care doctor, or preferably, from a pain medicine specialist. HOW DO I REDUCE STRESS ON THE JOINT? Getting to and/or maintaining optimal body weight is one of the most effective ways to reduce stress on the hips and especially, the knees. In fact, the knees, under impact activities, can amplify the body weight by up to 10 times! So loosing even a single pound can be the equivalent of taking up to 10 pounds off the knees under certain circumstances. Activity modification to avoid impact on the joints is also important. Unfortunately, activities such as running or competitive sports that involve contact or constant starting and stopping can place additional stress on the joints, and can aggravate, if not advance arthritis. Avoid these activities if possible, and make sure that proper and well adjusted equipment is utilized in any sport or activity. For instance, replace those walking or running shoes frequently to maintain optimal cushioning. And make sure that bicycle seat is adjusted comfortably high enough to avoid deep knee bends. Avoid lunges and squats. As a general rule, if it hurts the joint, stop! Alternative activities to consider include elliptical machines or newer arc trainers (whose motion may feel more natural than an elliptical), as well as swimming. In fact, anything in the water is better than on land in terms of reducing stress on the joint. And walking is still an acceptable alternative to higher impact activities. You may consider a knee brace of sorts for knee arthritis. While rarely providing enough support to substitute for failed ligaments, they provide your mind a constant feedback that tells your body to protect the joint in your usual daily activities. Knee un-loader braces are still available, but have been met with mixed results. Simple and inexpensive neoprene braces can offer similar relief. Finally, an assistive device of some type may also be used, including a walking stick, cane, crutch, or walker. These devices, used properly, share weight from the affected joint, transferring it to the upper extremities. A tip for those who use a cane, crutch, or stick: hold it in the hand opposite the side of the affected joint (for example, if your right knee is sore, use it in the left hand). Page 4 of 7

5 CAN T YOU JUST REPLACE THE CARTILAGE? In some instances, yes. These include isolated areas of cartilage loss, particularly in younger patients, in which no to minimal joint space loss has occurred. Unfortunately, this is a small group of patients, as by the time symptoms present, the arthritis is often too far advanced to offer successful outcomes with these types of procedures. Additionally, even replaced cartilage often heals just as scar. It s just never as good as the original cartilage. Joint spacers have been introduced in the past as well, but all have failed miserably. Some companies also market something called viscosupplementation as a type of lubricant or void filler. You may have even heard the name Synvisc, Orthovisc, or Euflexa from advertisements. These are essentially a series of injections made of the crushed-up comb of a rooster, sterilized, and turned into a gelatin. Again, results have been quite mixed, and I do not routinely offer these, as they have not been shown to be any more effective than placebo, and the quality of studies showing benefit has been called into question. The most reliable, durable and time-tested replacement of the cartilage, when it s time, is joint replacement, such as total hip or knee arthroplasty. WHAT IS JOINT ARTHROPLASTY OR REPLACEMENT? When all non-operative and conservative management options have either been tried or declined for good reason, then joint replacement offers reliable, reproducible, durable, and well-researched results as a surgical option. These procedures usually improve function, greatly decrease (if not eliminate) pain, and reliably improve quality of life. In joint replacement or arthroplasty, the destroyed joint is replaced or resurfaced with implants that substitute for the cartilage surfaces. These devices function similarly (although not identically) to the joint before it was diseased. Additionally, advancements in minimally invasive surgical techniques, pain medication regimens, and rehabilitation may make your recovery faster and easier than what has traditionally been experienced. Further and more specific information regarding joint replacement is available upon request. HOW DO I KNOW IF JOINT REPLACEMENT SURGERY IS RIGHT FOR ME? You and your surgeon can discuss if and when joint replacement is an appropriate option for you. In general, both radiographic (X-ray) and clinical (symptoms and exam) criteria must be met. Additionally, you must be healthy enough to tolerate surgery and the recovery afterwards. Surgery is not recommended for patients with advanced X-ray findings, but no symptoms, and likewise, patients with severe pain, but no significant X-ray evidence of advanced disease. Page 5 of 7

6 SUMMARY OF ARTHRITIS: - Arthritis is inflammation of the joint, typically caused by or linked to loss of cartilage - The end result of arthritis is joint destruction, with loss of motion, and often pain - Non-surgical treatment options for arthritis include: - Medications: - Oral anti-inflammatories (e.g. Advil, ibuprofen, Aleve, Celebrex) - These can increase risk of heart attack, stroke, kidney disease, GI ulcer - Pain medications - acetominophen (Tylenol) - tramadol (Ultram) - narcotic pain medications (not recommended for long periods) - Oral steroids - Can have systemic effects, and should only be used for short periods - Nutritional supplements: - Glucosamine-chondroitin (e.g. Cosamin, Osteobiflex, etc.) - Fish oil - Local joint injections: - Cortisone (e.g. Aristospan, DepoMedrol, etc.) - Time-tested, reliable, but no more than 3 per year - Viscosupplementation (e.g. Synvisc, Orthovisc, Euflexa) - Not highly recommended - Mixed results - Can cause an inflammatory reaction - Activity modification: - Avoid impact activities: running, jumping, squats, etc. - Engage in low-impact daily activity: walking, swimming, elliptical, biking - Good equipment, proper adjusted, good techniques - Maintain strength and flexibility - Weight-loss: - Decreases stress on the joints - Many medical programs are available - ask your primary care physician - Bracing: - Neoprene or rigid brace - Provides feedback so that you protect the joint - Walking devices: - Cane, crutch, walking stick, or walker - Use cane, crutch, or stick in opposite hand Page 6 of 7

7 SUMMARY OF ARTHRITIS (CONTINUED): - Surgical treatment options for arthritis include: - Cartilage transplant or replacement procedures: - Rarely indicated, and only for isolated areas in younger patients - Joint realignment procedures: - Indicated less commonly, in patients with symptoms of arthritis due to poor joint alignment, but no significant change in cartilage thickness - Arthroscopy: - Rarely appropriately indicated if there is joint space loss - Occasionally helpful for removing loose bone spurs floating around (loose body) - Clean out procedures are no longer indicated, and can hasten arthritic change - Joint replacement: - Excellent, most reliable and durable outcomes in appropriately selected patients - Can be performed using minimally invasive technique to make recovery faster and easier - See additional information for specific joint replacement discussions ADDITIONAL INFORMATION: Thank you for taking the time to learn about arthritis. We hope this article has been both informative and helpful in your decision-making process. Your bone and joint health is important to us! If you have any additional questions or concerns, or if you would like to discuss any of these options further, please do not hesitate to contact us at (616) , ext Kind regards, Dr. Pack, Kristin, and the RVO Staff Page 7 of 7